Mood Disorders. Major Depressive Episode Major Depressive Disorder Dysthymic Disorder Double Depression

Size: px

Start display at page:

Download "Mood Disorders. Major Depressive Episode Major Depressive Disorder Dysthymic Disorder Double Depression"

Jayson McCoy
6 years ago
Views:

1 Outline Primary vs. secondary symptoms Mood vs. affect Panic attack vs. panic disorder Acute Stress Disorder/PTSD Mood disorders: major depression and dysthymia Mood disorder treatment: CBT, IPT, and Recovery/empowerment model 1

2 Mood Disorders Major Depressive Episode Major Depressive Disorder Dysthymic Disorder Double Depression 2

3 Mood vs. Affect Mood A pervasive and sustained emotion that, in the extreme, colors the person s perception of the world Affect A pattern of observable behaviors that is the expression of a subjectively experienced state (emotion) Variable over time, in response to changing emotional states (vs. mood, which is pervasive and sustained 3

4 DSM Classification Major depressive episode Manic Depressed mood or loss of interest or pleasure Persistently elevated, expansive, irritable mood Mixed Manic and depressive symptomology Hypomanic Similar to manic, not as severe 4

5 Major Depressive Episode Depressed or irritable mood Loss of interest or pleasure [anhedonia] Weight changes Sleep problems [DFA, SCD, EMA] Motor agitation or retardation Loss of energy Feeling worthless or guilty Poor concentration Thoughts of death or suicide 5 of 9 symptoms for 2+ weeks Problems must cause impairment 5

6 Major Depressive Disorder Primary Symptoms (9 MDE symptoms from previous slide) Secondary symptoms: social withdrawal, temper tantrums, poor schoolwork, poor peer relations, alcohol and substance use Onset: age 5-19 Course: Variable; 26% to 70% have multiple MDE episodes within 5 years 6

7 Major Depressive Disorder Duration: median duration = 8 months for clinical samples [but for >1 yr for a majority of youth]; 1-2 months for community samples Prevalence: Children: 2% Adolescents: 4-8% Severity and duration: differential for MDD vs. dysthymic disorder 7

8 Mood Descriptors Euthymic normal mood state Dysphoric unpleasant mood (e.g., depression, anxiety, irritability) Elevated more cheerful than normal; not necessarily indicative of psychopathology Euphoric exaggerated sense of well-being; implies a pathological mood state (e.g., up in the clouds, flying high ) Expansive lack of restraint in expressing one s feelings, frequently with an overvaluation of one s significance or importance May be accompanied by elevated or euphoric mood Irritable internalized feelings of tension associated with being easily annoyed and provoked to anger 8

9 Affect Descriptors Appropriate consistent with content of person s speech or ideation Inappropriate when not consistent Broad normal Restricted limited in expressive range and/or intensity Blunted marked by severe reduction in the intensity of affective expression Flat virtually no affective expression; voice is monotonous and face is frequently immobile Labile characterized by repeated, rapid, and abrupt shifts e.g., tearful vs. combative vs. gregarious, vs. angry and abusive without apparent reason 9

10 Depression & Development Infancy Lethargy Feeding problem Sleep problem Irritability Sad expression Crying Failure to thrive Associated with maternal depression Preschool Lethargy Feeding problem Sleep problem Irritability Sad facial expression Crying Mood changes Hard to assess 10

11 Depression & Development Middle childhood Begin to report hopelessness and selfdeprecation around age 9-12 Throughout childhood: difficult/impossible to disentangle depression from anxiety Measurement issue or developmental phenomenon? Adolescent Begins to look more like adult depression May be differences between prepubertal and postpubertal depression 11

12 Major Depressive Disorder Point prevalence rate: 2% in school-age children; 4% in adolescents 1:1 gender ratio before puberty; female excess after puberty 1:2 males to females Cumulative incidence by age 18: 20% of community samples A majority of children w/depressive illness will have a recurrent illness: 20% - 60% by 1 to 2 years following remission; 70% after 5 years following remission (Birhaher et al. 2002; Costello et al., 2002). Episodes typically last 8 wks 9 months, and for more than 1- year for a significant majority [up to 14 months] 12

13 Major Depressive Disorder The clinical picture in children is similar to that observed in adults with some exceptions: Melancholy is usually not observed in children. Suicide attempts are less frequent in children. Lethality of suicide attempts is lower [note: children show a similar frequency of suicidal ideation & equal intent]. Children: higher frequency of comorbid separation disorder, phobias, somatic complaints, & externalizing problems [42% w/adhd, 62% w/odd, 41% w/both disorders Luby et al., 2003]. Approximately 5% - 10% of children & adolescents have subsyndromal symptoms of MDD, including significant psychosocial impairment & increased risk of suicide & developing MDD [also have high family loading for depressive illness]. 13

14 Diagnosis of Major Depression and Dysthymia in Pediatric Patients Primary obstacle: children cannot reliably report their internal feelings [i.e., identify and label mood states]. Children are notoriously poor at reporting time concepts & questions in which they have to exercise judgment use anchors and usually remembered dates (summer, holidays, birthdays). Use simple questions asked sequentially rather than complex questions. Must rely heavily on parental report, which in turn, is hampered by several variables including parental psychopathology, attachment/ closeness to child, observation of child, & ability to identify internal feelings in children [note: depressed mothers tend to over report depressive symptoms in their children]. Mood states are highly comorbid with ADHD, CD, and anxiety disorders. 14

15 Important Predictors of Depression & Recurrent Depression Comorbid nonaffective disorders predict a more severe course of depression. 45% of adolescents with a history of MDD develop a new episode of MDD between the ages of 19 and 24 (i.e., annual reoccurrence rate of 9% over a 5-year time span). Adolescents with MDD have an elevated rate of nonaffective disorders between 19 and 24 years of age, as well as elevated antisocial and borderline personality traits relative to TD controls. The prognosis of Adjustment Disorder is nearly as poor as for MDD rates of future MDD and nonaffective disorder for adolescents with adjustment disorder are as high as for those initially presenting with MDD. Adolescents who succumb to adjustment disorder with depressed mood in the face of a stressor are more vulnerable for developing future MDD as young adults (i.e., implies inherent vulnerability). Nearly all adolescents with MDD & dysthymia also had a non-affective disorder. 15

16 Depression and Anxiety in Children Kovacs et al. (1989): 2/3 s of children with comorbid anxiety and depression develop anxiety before depressive symptoms. Orvaschel et al. (1995): 64.5% of adolescents with anxiety disorder later develop a 2 nd diagnosis of MDD; but only 6.5% with MDD first later develop an anxiety disorder. Cole et al. (1998): Anxiety Depression Depression & anxiety are highly stable temporal traits [ over a 30 month interval] High rates of depression & anxiety predict increases in these constructs over time. The probability of developing depressive symptoms after manifesting symptoms of anxiety is 31%. The probability of developing depressive symptoms without previous symptoms of anxiety is less than 1%. There a 3-fold increase in the likelihood of experiencing depressive symptoms due to prior symptoms of anxiety but the converse does not hold. 16

17 Important Predictors of Depression & Recurrent Depression Greater severity, chronicity, multiple recurrent episodes, comorbidity, hopelessness, residual subsyndromal symptoms, negative cognitive style, family problems, low SES, & exposure to ongoing negative life events predict recovery, relapse, and reoccurrence. Dysthymia characterized by a prolonged course, with a mean episode of 3 4 years for clinical and community samples; also associated with an increased risk of subsequent MDD and substance abuse disorders (Kovacs et al., 1994). 17

18 Best predictors of which depressed children will later develop bipolar disorder: Rapid onset Psychosis Psychomotor retardation Psychotic features Family history of bipolar disorder Tricyclic induced hypomania 18

19 Masked Depression Based on the following misconceptions: Children are too immature cognitively and emotionally to experience core depressive affects. Children younger than 9 do not have a sufficiently developed self-concept and thus could not experience the discrepancy between the real and ideal self that is a necessary precursor to guilt a core emotion of depression. Psychoanalytic the superego has not fully developed at this age. Masked Depression conveys the notion that children will not express depression directly but rather indirectly through somatic complaints, aggression, and other nonaffective symptoms instead of typical symptoms of depression (sadness, anhedonia, etc). Joaquim Puig-Antich (1982) study: many children presenting with with CD symptoms may have an underlying depressive illness & CD symptoms may resolve following successful Rx of depression. 19

20 Diagnosis of Depression in Children Structured and Semi-Structured Clinical Interviews (e.g., K-SADS) CBLC/TRF: 1. Depressed school-age children have significantly higher internalizing T-scores relative to ADHD-ODD and no disorder children 2. Depressed school-age children have significantly higher depression/ anxiety, withdrawal, and somatization subscale scores relative to children with ADHD/ODD and no disorder children. Symptoms not reported by typically developing controls: a. Anhedonia 58% - high NPP: don t exhibit it, you probably don t have depression [reported by 0% in typical children] a. Withdrawn b. Afraid to leave home c. Unexcited d. Sadness/irritability high sensitivity almost all children with depression -- 98% -- report this symptom. 20

21 Diagnosing Depression in Children A majority of children with primary affective disorder exhibit behavioral problems that are viewed by their parents as disturbing; however, these problems are not viewed as the child s major problem (Carlson & Cantwell, 1980). The behavior problems of children with externalizing disorders are typically viewed as more serious by parents. A traditional evaluation with only the parent will miss approximately 60% of affective cases. Masking behaviors are typically nothing more than presenting complaints. In children with depression behavior problems are typically viewed as less severe and postdate the onset of depressive symptoms. 21

22 Major Depressive Disorder Primary Treatments Tricyclic Antidepressants (TCAs) or SSRIs Puig-Antich et al. conduct disorder study Cognitive behavioral intervention Behavioral family systems therapy Interpersonal psychotherapy 22

23 Dysthymic Disorder Depression less severe, but more chronic Depressed or irritable mood Appetite disturbance Sleep disturbance Low energy Low self-esteem Poor concentration Hopelessness Symptoms last for a year or more Double depression is a term used when the child has both MDD and dysthymia Dysthymia usually begins before MDD 23

24 Dysthymic Disorder Primary Symptoms: Two or more from previous slide Secondary symptoms: social withdrawal, temper tantrums, poor schoolwork, poor peer relations, alcohol and substance use Onset: age 8.5 Course: Variable Duration: At least 1 year; chronic, variable, or remits 24

25 Adjustment Disorder with Depressed Mood Child has depressive symptoms in response to a clear stressor (e.g., move, divorce) 25

26 Epidemiology MDD the most common type 80% of kids with depression have MDD 10% have double depression 10% dysthymia May be underestimated Episodes common in adolescence Gender differences do not occur until age 13 when girls report depression more often 26

27 Mood Course of major mood disorders (+) Mania Hypomania ( ) Time Normal Range Dysthymia Major Depression 27

28 Psychosocial Treatments for Depression Cognitive Behavioral therapy (Beck) Interpersonal Psychotherapy (Klerman) 28

29 Cognitive Behavioral Therapy (CBT) Beck (Cognitive Therapy) Ellis (Rational Emotive Behavior Therapy) 29

30 Physio/Chemical/ Hormonal Imbalances Depression/Dysthymia Perceived absence of contingency between person's efforts and reinforcing nature of consequences that follow Consider antidepressant medication Efforts to Bring (+) Reinforcement Inadequate Why is ability lacking? Perceptions of ability to control own world are distorted Environment is Unresponsive (Few reinforcements) Objectively competent, accurate perceptions i.e., the situation IS the problem Bx Deficits (Lack appropriate skills) Inhibitions Target distorted perceptions Target Perceptions Target Environment Bx Rehearsal Modeling Prompting Desensitization Reduce Anxiety Learn to like what you're doing Find other satisfactions Post-Competency Change view of self-efficacy Reinforce New Thoughts & Behaviors Self-monitoring Feedback Therapist & Peer Rational Restructuring Evaluate realistically demands and ability to meet then Problem Solving, etc. 30

31 Anxiety Conditioned Instrumental Deficits Lack of certain skills Selfgenerated Statements Overextending Self/ Too Much Responsibility Desensitization Selfmonitor Bx Rehearsal Self-induced Behaviors Life Situations Can client be taught to relax? Can client clearly imagine and become anxious? Will client agree to graduated exposure? Modeling Supplements Unrealistic Selfdemands Shoulds/Musts Tenable Environment? Imaginal Modeling Anxiety Level Perception of Other's Reactions Yes No in vivo Desensitization Rational Restructuring Evaluate realistically demands and ability to meet then Coping Skills Modify Environment 31

32 Cognitive Behavioral Therapy (CBT) Core Belief I m incompetent Intermediate Belief If I don t understand something perfectly, then I m dumb Situation Reading textbook Automatic Thoughts This is too hard. I ll never understand this. Reactions Emotional Sadness Behavioral Closes book Physiological Heaviness in abdomen 32

33 Automatic Thoughts Situation: Reading your textbook Reader s automatic thought This makes sense! Finally, a book that explains things clearly! This is too general when will I learn what I need to work with kids? This book is a waste of money I have to learn all this?! What if I don t understand it?!? This is too hard. I ll never be a good therapist The reader feels: Mildly excited Disappointed Disgusted Anxious Sad 33

34 Cognitive Behavioral Therapy (CBT) 34

35 CBT: Eliciting automatic thoughts 35

PSYCH 235 Introduction to Abnormal Psychology. Agenda/Overview. Mood Disorders. Chapter 11 Mood/Bipolar and Related disorders & Suicide

PSYCH 235 Introduction to Abnormal Psychology Chapter 11 Mood/Bipolar and Related disorders & Suicide 1 Agenda/Overview Mood disorders Major depression Persistent Depressive Disorder (Dysthymia) Bipolar